The results of the thematic analysis are presented in three sections below with the first describing the mental health issues facing athletes, the second describing barriers and the third describing facilitators. Within the barriers and facilitators sections, discussion topics are sorted into major themes, and minor themes and then ordered by relative importance as judged by the volume of the discourse created, measured by the number of words and ideas generated for each topic from both the verbal discussion and written activities. Participants are identified by number and gender (i.e., F1 = female participant number 1).
Mental health issues affecting athletes
The following is a summary of the themes that were raised during the course of the focus group, either from the initial discussion targeting this topic or during the barriers and facilitators discussion.
One of the strongest themes to emerge was the issue of performance. The participants felt that feelings of depression and anxiety could result from poor performance – M1: “I think after, if maybe after a competition you don’t perform very good, you can get depressed and stuff”.
They indicated that the pressure to perform came from various sources including themselves, their coach, and their families. They also emphasised their high levels of motivation and their perception that they must maintain high standards of behaviour in order to succeed. The athletes indicated that this focus on performance extended to psychologists and they felt that when they were scheduled to see a psychologist they were only able to talk about issues related to sport and performance.
F1: “When you try to talk about other things, they always relate it back to sport, and they relate it back to goals… even if you want to know about something else.”
Another important theme raised by participants was injury and the impact this could have on the individual. Depression, sadness, and anger were all discussed as potential outcomes for both short and long-term injuries. In addition, feeling left out of team activities was raised as a trigger for a change in an athlete’s feelings and behaviour. However, the participants also indicated that motivation to train and to remain a part of their team might assist them in the process of recovering from injury and depression.
Athlete appropriate behaviour
The participants felt that an important issue for athletes was the pressure to maintain a high standard of behaviour. They acknowledged that being an elite athlete was a privilege, and that this required them to behave in a certain way – M2: “You also have the pressures of being an elite sportsperson so you know, you can’t behave like your average person on the street”. The participants felt strongly that they were very distinct from, and subject to different rules to the general community – M3: “We are completely different from non-athletes. We have to be more disciplined, and don’t get to release pressure as much”. Defining themselves as somewhat separate from the community was a theme that recurred throughout the discussion.
The participants felt that eating and weight control was another important issue for athletes – F2: “Weight has a big issue in athletes…skinfolds and all that, so yeah I don’t know, some athletes find it hard to deal with that”. Notably, this was raised primarily by female participants as being an important issue for females in general.
F3: “I think with girls, it’s like the weight issue. ‘cause it is an issue away from sport and more so when you’re in sport, it’s a bit of a…it’s a high focus point.”
Living away from their families was a source of stress, as one participant stated – F4: “When I first came that was the worst thing, like leaving my friends and family behind”. Balancing their commitments to both their sport and studying were additional sources of stress.
The results for the written activities are presented first, followed by the results for the barrier discussion topics.
Figure 1 presents a concept map of the barriers to seeking help for a mental health problem for elite athletes reported by the participants in the self-initiated written activity. Overwhelmingly, many responses (18/41, 44%) related to stigma, primarily embarrassment, and the effect of help-seeking on social relationships.
Table 1 presents the top-ranked barriers as reported by the participants in the ranking written activity.
Public, perceived, personal and self-stigmatising attitudes to help-seeking
The issue of stigma was a primary topic. A common theme across groups was that participants believed that there was a qualitative difference between sport-related issues such as performance anxiety, or goal-setting and other mental health problems such as depression, with the latter being more stigmatised.
M3: “If it’s performance anxiety and everyone in the team knows their performance has been down then I don’t think it’d be too bad. But if it was like depression or something, then that’d be a bit different”.
The participants were more comfortable seeing psychologists for performance related issues – F3: “I think if anywhere, it’s more accepted to be able to go and see someone ‘cause it’s something that we have to do”. However, it was clear that this did not translate into a sense of comfort about seeing psychologists for any other reasons – F1: “I think most of the time with athletes it’s just like about like goal strategies, and stuff like that, and how to manage nervousness”.
The participants thought that personality was an important factor in whether the person would feel comfortable seeking help despite stigmatisation of help-seeking – F1: “Immature people tend to be a bit more like embarrassed to speak about what they’re feeling” and M3: “I’d say personality again…’cause I don’t care, but I know that other people that are seeking help would care”. The participants agreed that athletes would be worried about others finding out if they were seeking help for a mental health problem. Many of the comments related to the demands of being an elite athlete and being concerned that others would think they were not coping effectively or were “weak”. One of the participants remarked –
F4: “You don’t want them to think that you’re not handling the pressure…That’s the thing with athletes, like you’re not really supposed to show your weaknesses kind of thing, ‘cause that like lets your competitors know, so that’s why a lot of the time you wouldn’t go see the psychologist or whatever, just ‘cause that becomes your weakness.”
The athletes had differing views about who they would most be concerned about finding out that they were seeking help. Their coach was a much greater concern for older athletes than for younger participants. Teammates (and friends who were teammates) were also high on the list of those whom the participants would worry about – F2: “My coach and probably team mates, ‘cause we’re surrounded by that”. Participants also thought it could be worrying for athletes if their parents and family found out. Additionally, they were concerned about negative consequences of the social aspect of their friends finding out if they were to seek help. However, some of the participants thought this could be viewed as being a positive thing if it were close friends – F2: “Some people wouldn’t probably mind their close friends knowing ‘cause then the support network they could build to help them get through it would be good”. When asked what athletes thought of other athletes seeking help, the responses were supportive and non-judgmental – F2: “I think it’s good if they’re getting help and they’re dealing with what the problem is, then it’s good for them”. However, when prompted, many of the participants thought that confidentiality with help-seeking was very important and they rarely, if at all heard about other athletes seeking help. Despite the apparently accepting attitude of the majority of their peers, many participants were very reluctant for anyone to know if they themselves were to seek help.
F2: “It just makes it worse for the athlete that needs the help, and maybe it would just make them shy away from, them thinking they have a problem, like pretend that there’s nothing wrong ‘cause they don’t want people looking at them differently.”
Participants agreed that the media had a large role in determining what the public would think of an athlete seeking help for a mental health problem. Overwhelmingly, the media was thought to exaggerate and exacerbate the issue for them, and make the individual “feel worse about their problem…Instead of focusing on the positives of them trying to get help, it’s just them putting them down all the time” (M4). Others felt that when well-respected athletes actively chose to publicise their help-seeking for mental health problems, that this could be received in a positive way, and could also be useful for athletes.
F2: “I think it makes…other people in the world that aren’t athletes realise that there’s nothing that’s different between us superstar athletes, as they might put our names to - you know, we’re all the same.”
Lack of knowledge about mental health services
The participants considered that lack of knowledge about the services available and how to access them could act as a barrier to seeking help. However, they thought that this would primarily affect athletes living away from a centre like the AIS, who may not have direct access to services – M5: “If you were living at home you wouldn’t really know where to go”. Participants agreed that a lack of knowledge about what might happen in a consultation could act as a barrier for an athlete seeking help. Most thought that feeling worried about being uncomfortable approaching someone for help, or being frightened about not knowing what to expect could act as a barrier. The participants also thought that some athletes might feel anxious about what they expected would happen during a session with a counsellor or psychologist – F2: “Some people may find it hard to sit just one on one with someone, ‘cause it’s awkward or uncomfortable for them…it’s sometimes hard to talk about your own weaknesses”. They felt that some athletes may be concerned that a health provider would not understand their problem – M3: “I think sometimes you don’t know whether the other person is going to understand or not”, particularly if it was the athlete’s first visit. The athletes also indicated that they were uncertain about when it might be appropriate to see a professional – F4: “Well sometimes you don’t know what to say, like you can’t just go up to a counsellor and say, well I’m a bit sad”. The participants were not sure which professionals were appropriate for mental health problems.
F4: “The psychologists here are sport psychologists, sometimes things that happen away from sport you’re not sure whether you can go and see them about that, or is that an issue for a counsellor.”
However, they were unanimously adamant that general practitioners were not an appropriate first source of help for mental health problems.
M6: “I always thought of doctors as like second referral, like you go to a counsellor or a psychologist and then you go to a doctor after that, if they think you should, or if it’s not working.”
Lack of knowledge about the symptoms of mental disorders
The participants considered that lack of knowledge about the symptoms of mental disorders was an important barrier to seeking help for athletes. They raised the point that depressed mood and “up and down emotion” (F1) was “an everyday occurrence” (M3) for elite athletes in their position. They explained that they experienced regular physical strain and found it difficult to distinguish between the fatigue caused by this physical exhaustion and depression or anxiety.
F2: “Being an elite athlete isn’t easy…you’re pushing your body to extremes almost every day and sometimes you do get depressed and, or upset or down because you’re always almost totally fatigued every day. So sometimes, I guess…you can blame your depression and anxiety and that on fatigue, when it might not be the fatigue that’s creating the depression or the anxiety. But you could put a cover on it like that, saying it’s from training.”
The participants acknowledged that athletes might find it difficult to apply their knowledge of the symptoms a depressive or anxiety disorder to themselves. They might be knowledgeable about the symptoms of these mental disorders, but not know if what they were experiencing was “just a feeling” (F1) or indicative of a mental disorder – F4: “Maybe it’s not so much like, you don’t know about mental disorders but you don’t realise that you might have it”. This also applied to eating disorders. However, according to the athletes, eating disorder differed from anxiety and depression in that that the athlete experiencing the symptoms might not be aware that they had any sort of problem at all, even when others around them clearly perceived the problem.
F2: “They’ll just keep going on with what they’re doing thinking that it’s right, but the people around them can see that it’s not, so they might not even know that they’ve actually got a problem.”
This theme of having someone else recognise the problem before the individual was common. Coaches and other people close to the athlete were viewed as being in a position to see the need for help in some cases – M3: “I went to get help after the coaches told me”.
Negative past experiences
The participants felt that past experiences could act as a barrier to future help-seeking. They had access to free counselling with certain providers. However, a problem in relating to this provider in the initial consultation could act as a barrier to them returning to this person for help.
F1: “My coach always used to make me try and go see [a certain psychologist], and I didn’t like it, and so I’d sit in there for the whole session and I wouldn’t want to say anything, and just ‘cause she was really like, not the type of person that I wanted to talk to.”
The participants thought that this could even hinder them from seeing a different person for help – F2: “Yeah, definitely if you had a bad experience you wouldn’t want to try it again with someone else”. It was thought that a close relationship with the provider would act as less of a barrier to future help-seeking. The greatest barrier to future help-seeking was a breach in confidentiality – F2: “If you lost your trust in someone, and they said something to someone else”.
There was some disagreement about whether lack of time was a barrier to seeking help. Notably, the younger participants indicated that if you really needed help, you could “always find time” (M3). However, the older participants considered that time constraints were a significant problem – F2: “If you do have the time you just want to be resting. ‘Cause you sometimes think that the fatigue is creating what - the depression or whatever”.
As part of their scholarship, AIS athletes are provided with access to a range of services including psychologists on location at no personal cost. Considering these arrangements, the participants felt that not having enough money or transport to seek help was not a major issue for elite athletes in their position. They did acknowledge however, that it would be more difficult for lower level or more isolated athletes who did not have easy access to cost-free services – M6: “If it wasn’t free, I wouldn’t go”.
The participants agreed that gender would definitely be a barrier for athletes, in that males would find it harder to seek help than females. They thought this could be because males perceive seeking help as a “sign of weakness” (M4) or as an act which lowers their “social status” (M4), and they are less able than females to articulate their feelings. Age was also thought to be an important barrier, although some participants believed that younger athletes would be less likely to seek help, and others indicated that older athletes might be more confident and perceive themselves as better able to manage their own problems.
The results for the written activities are presented first, followed by discussion topics. Facilitators were generally discussed in much less detail than barriers, and the participants generated more diverse responses.
Figure 2 presents a concept map of the facilitators for elite athletes in seeking help for a mental health problem as reported by participants in the self-initiated written activity. The largest number of facilitators were reported in the topic of education and awareness of mental health issues and services (10/45, 22%).
Table 2 presents the top-ranked facilitators as reported by the participants in the ranking written activity.
Encouragement and the positive attitudes of others
Participants differed in their views about whether it would be useful for others to encourage an athlete to seek help. Some viewed it positively, particularly if it was the coach offering advice. Notably, participants thought that their coach could act as a gatekeeper to services – F1: “Sometimes if there’s a problem you sort of talk to your coach, and maybe then they’ll tell you if you need some more help or something”. Additionally, they thought that it needed to be dealt with very sensitively and only by someone close to the athlete. They felt it would be acceptable if the encouragement organically arose from a discussion with a person close to the individual who was respected and trustworthy.
F1: “If you’d like been talking about issues, but you hadn’t really discussed about getting help, and then someone would say to you, like do you think you should get help then that would be ok, I think, but not for someone to say to you – ‘you need help’”.
Despite this, the participants felt that the decision to seek help was ultimately up to the individual and that encouragement would not necessarily be useful unless the person wanted to seek help.
The participants generally agreed that it was important that others around the athlete including their family, coach and friends had positive attitudes towards seeking help, and that this was an important facilitator – M7: “probably the biggest one I think”. Some thought it would not be helpful if their coach knew – F4: “I don’t think it would help, like you still feel a bit uncomfortable if they know”. Others believed it could be very helpful if their coach knew and had a positive attitude towards seeking help – M1: “Coach is probably the one that’s going to have the most influence over you”.
Established relationship with provider
The majority of participants felt that having an established relationship with a health professional would act as a facilitator to them seeking help. Overwhelmingly, they thought that knowing the psychologists they would be accessing made it “easier if you need help” (M4). However, other athletes acknowledged that knowing the counsellor might only be important for some athletes, in that some people would feel more comfortable with professionals regardless of any previous relationships.
Access to the internet and online mental health services
Generally, the participants felt that anonymous access to the internet may act as a facilitator for a small minority of athletes who may not feel comfortable approaching a health provider in person – F2: “I think that’s good for people that find it hard to I guess talk one on one”. The participants felt that the internet facilitated access to information and services, but had concerns about their quality. They felt that a small minority of athletes may want to use online mental health services on the internet, yet that most athletes would have enough confidence to talk to someone face to face – M4: “Depends on the person, ‘cause some people would want to speak face to face, while others find that way easier”.
Participants had differing views about whether awareness of feelings played a significant role in facilitating an athlete to seek help. Some thought that it was useful in seeking help – F1: “Well you have to know what’s wrong with you to talk about it, you need to be open to talk about it as well”. However, others believed that personality and openness of feelings would be more useful in assisting them during a psychologist or counselling session, rather than in the act of seeking help.
Characteristics of provider and support staff
Most participants thought it was of little importance for the support staff such as receptionists to be friendly. Yet it was considered important for the provider themselves to be friendly – M3: “for the counsellor it’s very important…you wouldn’t want to deal with them if they’re not”.